Understanding the RUC Survey Instrument November 2013

Understanding the RUC Survey Survey basics Purpose of the survey Who does what? Breaking down the survey into 7 easy steps Still have questions? What happens next?

Why are the surveys being conducted? Your societies need your help to assure relative values will be accurately and fairly presented to the Centers for Medicare and Medicaid Services during this revision process. This is important to you and other physicians because these values determine the rate at which Medicare and other payers reimburse for procedures.

When are responses due? Please submit your response by the date provided in the you receive The timeliness of your response is critical because data will need to be analyzed before it can be submitted to the RUC.

Purpose of the survey To obtain estimates of the time and complexity required in performing a procedure To obtain estimate of a recommended professional work value

How the survey works The survey asks you to compare the time, complexity, and work to perform the surveyed procedures to an existing procedure A list of possible reference procedures is provided for comparison purposes

Who does what? AMA/Specialty Society RVS Update Committee (RUC) Oversees survey process of codes Recommends physician work & practice expense values to Centers for Medicare & Medicaid Services (CMS) Societies/Associations Coordinate process for respective professions Distribute work surveys to members to obtain work & practice expense data Submit survey results to AMA RUC

Who does what? Specialty societies submit recommendations to the RUC for physician work, practice expense inputs and professional liability insurance crosswalks Recommendations are presented at the RUC meetings which occur three times a year

Who does what? The RUC sends its recommendations for work values, practice expense inputs and PLI crosswalks to CMS in May which are confidential until the CMS publication of the Final Rule in November. Values go into effect in January of the following year.

Partitioning the survey into 6 easy steps STEP 1 – Review code descriptor and vignette (a short description of the patient) STEP 2 – Review introduction & complete contact information STEP 3 – Identify a reference procedure STEP 4 – Estimate your time STEP 5 – Compare the survey procedure to a reference procedure STEP 6 – Moderate Sedation STEP 7 – Estimate work RVU (relative value unit)

STEP 1 Review code descriptor & vignette The vignette describes a TYPICAL clinical scenario for the procedure You may have performed the procedure on a patient different than the ‘typical’ one described in the vignette – that’s okay.

STEP 1 Continued Complete the survey instrument using the typical patient described by your society. The survey instrument allows for you to inform them that you do not believe the typical patient as defined is typical.

STEP 2 Review introduction & complete contact information Although contact and basic practice information is collected, your name is never forwarded to the AMA or used for tracking purposes. If you have any questions, a specialty society’s contact information will be provided

STEP 3 Identify a reference procedure List of reference codes – the survey includes a list of procedures that have been selected for use as comparison for this survey because their relative values are sufficiently accurate and stable to compare with other services. Select a procedure from the list that is most similar in time and work to the new/revised CPT code descriptor and typical patient/service described. Reference procedure does not have to be equal in work in your judgment to the surveyed procedure but it should be similar in work

STEP 3 Identify a reference procedure It is very important to consider the global period when you are comparing the new/revised code to the reference code A service paid on a global basis includes: Visits and other physician services provided within 24 hours prior to the service Provision of the service Visits and other physician services for a specified number of days after the service is provided (000 day global = 0 days of post care included in the work RVU, 090 day global = 90 days of post care included in the work RVU)

STEP 4 Estimate your time Using the vignette and the description of service periods, this section of the survey asks you to estimate how much time it takes you when you perform the procedure. These estimates should be based on personal experience.

Pre-Service Period – Defined The pre-service period includes physician services provided from the day before the operative procedure until the time of the operative procedure

Pre-Service Period – Defined The pre-service period may include the following: Hospital Admission Work-Up Pre-Operative Evaluation Dressing, Scrubbing, Waiting and Positioning the Patient The pre-service period does not include: Consultation or evaluation at which the decision to provide the procedure was made Distinct evaluation and management services provided in addition to the procedure Mandated services

Intra-Service Period Defined The intra-service period includes all “skin to skin” work that is a necessary part of the procedure

Post-Service Period - Defined Post service period includes physician services provided on the day of the procedure after the procedure has been performed

Post-Service Period - Defined The post-service period may include: Post-operative care on day of procedure Non skin-to-skin work in the OR Patient stabilization in the recovery room or special unit Communicating with the patient and other professionals Patient visits on the day of the operative procedure The post-service period does not include: Unrelated evaluation and management services provided during the post- operative period Return to the operating room for a related procedure during the post-operative period Unrelated procedure or service performed by the same physician during the post-operative period

STEP 5 Compare the procedure to a reference procedure – intensity/complexity In this step you will be asked to compare the complexity and intensity of the procedure being surveyed with the reference procedure In evaluating the work of a service, it is helpful to identify and think about each of the components of a particular service. Focus only on the work that you perform during each of the identified components.

Definitions Physician work includes the following elements: The time it takes you to perform the service The mental effort and judgment necessary with respect to the amount of clinical data that needs to be considered, the fund of knowledge required, the range of possible decisions, the number of factors considered in making a decision and the degree of complexity of the interaction of these factors The technical skill required with respect to knowledge, training and actual experience necessary to perform the service

Definitions continued.. The physical effort required to perform the procedure. Physical effort can be compared by dividing services into tasks and making direct comparisons of tasks. In making the comparison, it is necessary to show that the differences in physical effort are not just reflected accurately by differences in the time involved; if they are considerations of physical effort amount to double counting of physician work in the service

Definitions continued Your psychological stress Two kinds of psychological stress are usually associated with physician work. The first is the pressure involved when the outcome is heavily dependent upon skill and judgment and an adverse outcome has serious consequences. The second is related to unpleasant conditions connected with the work that are not affected by skill or judgment. These circumstances would include situations with high rates of mortality or morbidity regardless of the physician’s skill or judgment, difficult patients or families, or physician physical discomfort. The first type is the only form of stress accepted as an aspect of work.

Definitions Physician work does not include services provided by support staff who are employed by your practice and cannot bill separately including: Registered Nurses, Licensed Practical Nurses, Medical Secretaries, Receptionists and Technicians

STEP 6 Moderate Sedation Moderate sedation is a service provided by the operating physician or under the direct supervision of the physician performing the procedure to allow for sedation of the patient with or without analgesia through administration of medications via the intravenous, intramuscular, inhalational, oral, rectal or intranasal routes. For purposes in the RUC survey, sedation and analgesia delivered separately by an anesthesiologist not performing the primary procedure is not considered moderate sedation. Is moderate sedation provided in the surveyed and/or reference code and in what setting (Facility/Non-Facility)?

STEP 7 Estimate Work RVU VERY IMPORTANT In this final step you will be asked to estimate the work relative value unit (RVU) You are asked to consider the value assigned to the reference procedure in developing your estimate The survey methodology attempts to set the work RVU of the procedure “relative” to the work RVU of the comparable and established reference procedure

Still have questions? Contact: Debra Lansey, ACP Health Policy & Regulatory Affairs Dept. or (800) extension 4544